Mental imagery and its role in the psychopathology and treatment of obsessive-compulsive disorder: a systematic review and narrative synthesis

Whilst intrusive mental imagery represents a diagnostic feature of obsessive-compulsive disorder (OCD), research is lacking with most focussing on intrusive thoughts. Moreover, it has been argued that mental imagery might represent a unique form of OCD symptomatology and could be harnessed to treat symptoms. We performed a systematic review, adopting a two-phased approach, to examine the role of mental imagery in both the psychopathology and treatment of OCD. First, we explored the characteristics and pathological features of intrusive imagery in OCD. Second, we evaluated literature examining imagery-based interventions, i.e., Imagery Rescripting (ImRs) and Eye Movement Desensitisation and Reprocessing (EMDR), in treating symptoms. Findings identify distressing mental imagery as a prominent feature in OCD. Intrusive imagery in OCD was characterised as vivid distressing visual images often accompanied by bodily sensations. Compared to other anxiety disorders, intrusive imagery in OCD occurred more frequently, which often led people to believe they possessed a “dangerous self”. Up to 89% of OCD patients reported experiencing intrusive imagery, with 70% to 79% also reporting that the intrusions related to adverse or traumatic events. Image-based treatments like ImRs and EMDR were found to be promising in reducing symptoms, providing an effective alternative treatment for patients suffering intrusive imagery.